HomeMy WebLinkAbout0072 SAINT JOSEPH STREET �� S� . �"oseph �5�.
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,tom Town of Barn le *Permit# : - 1 f
p ®� �Tres 6 months from issue date
Building Departmel ko,` Vee
awxwsrea[.E Brian Florence,CBO �`
MASS.
16396 � Building Com�' 'over ' 0
iOrED NIA'1 200 Main Street,Hyamii APR.01
www.town.barnstable.ma.t o,�
Office: 508-862-4038 °1� � Fax: 508-790-6230
L�
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 2�
Property Address ' V6 e
L� of
Residential ' Value of Work$ o0 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address V r 1`,r\f-Ae ! ,E��i e?,•
VY\F
Contractor's Name 'D�`� �" l.c7� Telephone Number
Home Improvement Contractor License#(if applicable) L- 1 �7 Email:
_ Cad
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name C �I
Workman's Comp.Policy# CA a Vt(71( lD�
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) �`�
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over' existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
•Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
equired.
SIGNATURE:
QAWPFILESTORMSTMESS2017
°F'ME r Town of.-Barnstable,
Building Department
` BAMSTABL. ' Brian Florence,CBO
ArE py�, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.maxs
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete'and Sign This.Section
If Using A,BuilUer
as Owner of the subject property
hereby authorize 5�� �� to act on my behalf,
in all matters relative to work authorized by this building permit application for:
( dress of Job)
**Pool fences and alarms are the responsibility of the applicant Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
S' _ature of net Signature of Applicant
P '.t Name Print Name
Date
Q:FORMS:OWNERPERMISSIONPOOLS
Rev:10/17
Town of Barnstable
FTNE rc Building Department
c� Brian Florence CBO
- Building Commissioner !
MAE& 200 Main Street, Hyannis,MA 02601
9 i639.
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-oc2oied.dwellings of six units or less and
ers to engage an individual for hire who does not possess a license,provided that the owner acts
to allow homeowners P
as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
hom g P
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
es and requirements and that he/she will comply with said procedures and
minimum inspection.procedures q P Y
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required
shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);
provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act
as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of
a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15)
This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed
persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,
as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a
Supervisor. On the last page of this issue is a form currently used by several towns..You may care to amen
d
P P g
and adopt such a form/certification for use in your community.
The Coarmomvealth o,f Massadiusetts
Department of Indurtrid AcciderLft
Qfflce a,f I gvtions
600 Wasbbigtozz&met
BoStofl,MA 012HI
nwmmasmgm1dia
Workers' Campensaf an Insurance Affidavit Bu lderslCtntractursMecEricianslPlumbers
AmUcant
Informatran ' Ple2se Print f,e�iblY
1V SHIP,(�cin�cclY5ea8III7�3,4Il1� ��.�`(`7� l�J�V
Addrt Z�j o4t P—C
Cify/stahj ®a-e6y:At, M a 8 phase- �b S d 7 `7
Are you an employer?Check the appropriate box: Type of project(required):
I� I am a employes with cam- 4 ❑I am a general contractor and I 6- ❑New poi:
employees(fall andfor part-ice s have hired the sub-contractors
2.0 I am a sale proptietor•or partner- Hi ed on the attached sheet I 0 Remodeling
These sub-contractors have ship Gild haL*a IIo.�pl-0�yeefi _ 8--0 D2mdlitiDtt
worldng for ale in any employees and hnre wornere
INQ wddceL3r'CIDTFlp. Ct7s11p_mcrtrarfrr
$ 9. ,0 Building addition
reqaire&) 5. 0 We are a corporation and its 10-E-1 Electrical repairs or additions
3.El am a homeowner doing all work officers have exercised their 1 L Plumbsng repairs or additions
o rockers' - right of exemption per MGL
insurance e�d-j y c.152,§I(4�and we have no 1-2 ofreparzs
employees-[No wrlcers' 13.E Other
cam-issuance )
•Ekay 9VHCMtdst ehet3M boa i%l—si alsa fMo=the swdmbeiaa sbvv in&eiraakere compeflmdmporieyiafb mstimL
T Someownem who snbmitt&S ai3ulaeit i g dney are china all gash and&ea hire cutsi&cant xctarsmnst submit a new affidaeat infairsitinsir di
fCoutu+ctM that 111-1 tbds box mast attached as additi— sheet dvwl=g the noes of fe and state whe m or sot these entities ham
employees.Iftbesnb-c==ctoe km empioyeas,tFwynmstpmuide thek warkere camp.porky aumbm
I am an employer tleatis prouitiir;g workers'coaxpensrrkan iumira cca or my earpinyvem Below is ifte paticy and jolt seta
informs om f�
Insurance Company Name:
Pflficy#or Self-ice Lic. lrA US FxpiiafibuDate: `I 7-2z. b
Job SiteAddmss: 7�5[7.S10Li City lStatelzisp:
Attach a copy of the work-ere compensation policy dedtaration page(sho-wing the policy number and expiration date).
FaRnre to secure coverage as required under Section 25A of MGL c.M can lead to the imposition of criminal penalties of a
fine up to$1,54a OD anifor one-year imprisonment,as we11 as civil peualties.in the form of a STOP WORK ORDEAand a Ee
th of up to$250-00 a day againste kziolator. Be advised that a copy of this statement may,be forwarded to the Office of _
Investigations ofthe DIA for insurance coverage verification-
l do Bata cerdrfp n e pains arldpe?JaIfixs o,fperjitry that the informadmi-provuWabrw rs Pw and cvrrect y
Si�ature: L Date , L I ( D
Phone# ,5(rzlo 1
tfiWi L use only. Do stot write in tlds area,tube,completed by city or town officiaL
City or Town: - PermitUcease#
Issuing Authority*(circle one):
L Board of Health I Building Department 3.f:tp Town Clerk 4.Electrical inspector S.Fhrmbiag Inspector
6.Other
j
Contact Person: 1 Phoane#:
Information and Instructions
Ma ccachrusets Geheral Laws cbapt�r M regaII:=all employers to provide workers'compensation far their=pIoyees. �
PmMrautto ibis star,an rMployW is defined as.¢_.evmy person in the service of another mdPd any cozdract of htr,
empress or implied,oral or vrh ."
An.Mayer is defined as"an mdbidnal,part aeash�p,association,corporaion or other legal entity,or any ttivo or more
inc the le eabdves of a deceased emplayer,or the
in a"omt ,and hrdmg girl repres
of the, engaged J foregoing
receiver or trustee of an individual,partnership,association or other legal entity,employing employees- However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occapant of the -
dwnlling house of another who employs pessans to do mace,contraction or repair work on such dwelling house
or on the grounds orbnildmg aPP urtea rat thereto shall not bmanse of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that¢every sty or local licensing agency shall withhold the ismance or
renewal of a Hcense or permit to operate a business or to construct buRdings in the commonwealth for airy,
applicant who has not produced acceptable evidences of cdmplimre with the himrance.covexage,repaired_"
Additionally.MGL chapter 152,§25C(7)states'Neither the cammaawm1h nor ray of its political subdivisions shall
eater into any Mn[t act for the perf=ante afpubho work-until acceptable evidence of compliance with the fimu-ance,.
r ez Tkenimts of this chapter have been presented to the,cow-rtIng arttTaoiiiy."
APPHcants
Please f H obt the workers'compensation affidavit completely;by checking the boxes that apply to your situation and,if
necessary,supply s h,-contractar(s)name(s), addresses)and phone numbers)along with their=tda—cate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liabffity Partnerships(LLP)with no employees other.ihm the
members or partners,are not required to cagy workers'compensation Dance_ If an LLC or LLP does have
employees,a policy is rued. Be advised that this affida:M maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be-retzmzed to the city or town that the application for the peonit or license is being requested,not the Department of .
ExhrcfriaT.A cci enfs Shouldyou have any questions regarding the law or ifyou are required to obtain a workers'
compensation policy,please call the Department at the:number listed below. Self-insured companies should ear their
s elf-mmn-ance,license number on the appropriate line.
Ci�or Town Officials
Please be sure that the affidavit is complete and primed legibly. The Department has provided a space at the bottom
of the affidavit for you to fry out in the event the Office of Investigations has to contact you regmdmg the applicant
Please be sure in fill in the peunit/licrose mnabes which will be,used as a refc=ce number: In-addition,an applicant
that must submit muht ple permitllicense,applications is any given yeer,need only submit one affidavit indicating cmreat
policy information.Cif nwzssary)and under"Tob Site Address"the applicant should wiifie,"all locations in (city or
town)."A copy of the-affidavit that has been officially stamped or marked by the,city or town may be provided to the
applicant as proof that a valid affidavit is on fire for Ritue'pmmits or licenses_ A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial 4entUrt
(Le. a dog license or permit to bum leaves etc.)said person is NOT regoired to complete this affidavit
The of of Investigations would hie to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Depm-truenfS address,telephone and;ffix MMbCr-
Co�o�TMjtbE of Massachnwib
Degarbm of luda�Accidents
Q Win
Rostan=11 A 0�1II
Tf, 617 7 -4 Mt 4 car I-��1�A�,4�A
Fax#617 727 7749
Revised 4-2"7 1w m s_gckv
r
ACCW O® CERTIFICATE OF LIABILITY INSURANCE FDA04/14/201TE 7`"'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsements.
PRODUCER Erica H.O'Connor
HART INSURANCE AGENCY,INC. NAME:
243 MAIN STREET PHONE FaAXC No:
PO BOX 700 ao�L: eoconnor@hadinsuranceagency.com
BUZZARDS BAY,MA 025320700 INSURERS AFFORDING COVERAGE NAIC#
INSURER A: SAFETY INSURANCE COMPANY 39454
INSURED Scott Lohr dba Lohr Home Improvement INSURER B: ACADIA INSURANCE COMPANY 31325
23 Grand Oak Rd
Forestdale,MA 02644 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH.RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDPOLICY EFF MM//DD/OLICY EXP LIMITS
A COMMERCIAL GENERAL LIABILITY BMA0024755 01/08/2017 01/08/2018 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE IV OCCUR DAMAGE PREMISES S( RENTED 100,000
Ea occurrence) $
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY❑JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per a.,de t
$
UMBRELLA LIAB
OCCUR EACH OCCURRENCE $
EXCESS LIAR HCLAIMS-MADE AGGREGATE $
DE D RETENTION $
B WORKERS COMPENSATION ASSIGN201704131240119687 04/13/2017 04/13/2018 SPE
TAR
AND EMPLOYERS'LIABILITY rurE oRH
ANY PROPRIETOR/PARTNEPJEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? ❑ N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below El.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
/
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988-2015 ACORD CORPORATION. All rights reserved.
.ACORD 25(2016/03) The ACORD namg and logo are registered marks of ACORD
u n1 0 /.l(,
License or registration yalid.for individual use only !` C+lncr of�:'onsumer Affairs&Business Reguladc�u
before the expiration date. If found return to: �a HOME.IRAPROVEM7ENT CONTRAOTOR;`.
Office of Consumer Affairs and Business Regulation ii
Registration i i72172 Type:
10 Park Plaza-Suite 5170 �. Exp�ratian 5/31/2018 DBA"
Boston,MA 02116. LOHR
HOME IMPROVEMENT
j $COTT LOFiR s°< -
ti =
23 GRAND.OAK RD."
— FOREST DALE,MA 02644
Not alid without signature a.' Undersecretary
JauOISSluUw00 '
tN9Z0 tl:W 3iVGIS3HOJ
U21 Htl0 UNVH!D£z
aHOI V 1100S
6LOZ/60/90 :Sajid��-3 .._ 1,96£SO-SO
JOSIAJ P. u i• rrJ�suoO
5H.g.
spjepue3S pue suoijein6aa 6uippn8;o pieo8
ainsuaDi-I ieuoissajad 10 uOisinip
V* Town of Barnstal
Building,
BAMUMA
Permit
Permit No. B-18-1233 Applicant Name: William McCluskey Approvals
Current Use: Structure
Date Issued: 05/18/2018
Permit Type: Building-Insulation-Residential Expiration Date: 11/18/2018 Foundation:
Location: 72 SAINT JOSEPH STREET, HYANNIS Map/Lot: 291-217 Zoning District: RB Sheathing:
Owner on Record:
.
1st�,,Project Cost: $5,000.00 Chimney:
...—.~~-^ .,.` 02601
Description:
Air seal the attic plane and basement with expandi'ng' a"' General
________.
5/18/2018
Project Review Req: Installers certificate required to close
Rough Plumbing:
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work autIh6die&byit his permit is commenced wit Rough Gas:
ic
ic permit has been granted.
All work authorized by this permit shall conform to the approved appi atidn4hidthgapproved construction docume
Final Gas:
All construction,alterations and changes of use of any building and st in compliance with the local zon!%n aws a' d codes.
This permit shall be displayed in a location clearly visible from access streetorroa&ancl shall be maintained open fot,,,ptiblic inspection forthe entire duration ofthe
Electrical
work until the completion of the same.
o I MI",
The Certificate of Occupancy will not be issued until all applicable signatures- Ali d ndFfire'Off Jc ia ska ir
Minimum of Five Call Inspections Required for All Construction Work:
X Rough:
1.Foundation or Footing L"IJ 121-1
2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Final:
7.Final Inspection before Occupancy
Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final:
Work shall not proceed until the Inspector has approved the various stages of construction.
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Building plans are to be available on site
All Permit Cards_are _the property_ the APPLICANT-ISSUED RECIPIENT
Town of Barnstabl_i . '*rermit#ZQ 151� b
� raiss date
Regulatory Services , 0
6
KAM
' Richard V.Se Interim DirectorT®� OCT 3 2015
Building Division Of 948/V
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis;MA 02601 [
www townbamstablemkns
Office. 508-862-4038 Fax:508 790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
NotVaWwithoat"JX-Pressl Tint
mlWarcel Number Z Z 1 7 ,
Property Address 7 /iVTjr�9!iMIvy
XResi&. 0tial Value of Work$ 6�3 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address MA l2I fNf--
Contractor's Name MAT e - Telephone Number 4b�—7`�`�O j
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable) 07W Z 7
i
Workmen's Compensation Insurance
\\ Check one.-
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurancece CompanyName /ur-9) �
Workmen's Comp.Policy# W t 2
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Wmdows/doors/sliders,.U-Value a (maximum 35)#of " dows
#of doors.
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required.
Separate Electrical&Fire Permits rajah-ed.
-Whem requite& Issoaaz offts pewit does not exempt a mpiimcewith other town department tegu]atmv,Le.Msme,Con=vatio%etc.
***Note_ Property er gn Property Owner Letter of Permission.
A copy of H Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
MWEM D1Bmlding Changes S racteEvitdoc
Revised 061313 ,
FROM :jamgad FAX NO. :5083622271 Apr. 25 2012 11:50AM P1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
In Sold,Fu nished and installed by:
Branch Name:Boston North&South Date:r=/�/1 THD At-Home Services.Inc.
d/b/a The-Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Fret 877-903-3768
Federal TD#75-2698460;ME Uc#C t12439;RI Cont.Lie#16427
CT LIc'ti HIC11565522;MA Horne Improvement Contractor Reg.#126993
installation Address: O Z/0 O
Ci State Zip
Purchaser(%): Work Phone: Home Phone: Cetl Phone:
f l [ l [ ]
Home Address;
(Tf different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing emails from The home Depot
Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THI)At-home Services,Inc.("The Horne Deput")agrees to furnish,deliver and an=g 'for the installation("Installation")of
all materials descaibrd on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
Job#: awe.wtaer—) oducts: S Sheets #: Pro Amount
�/ Rixlfing Siding Windoa- LJ Tn'sulution
❑Gutters/Covers ❑Entry Doors ❑_ $ a
Rcx)tin- LISiding 0 Windows U insula:iun $
❑Gutters/Covers ❑Entry Doors ❑
Rooflng LJ.%ichng Windows insulation $
❑Gutters/Covers ❑Entry Doors El
Roofing LjSidin.g U Windows U Insulation
❑Gutters/Covers ❑Entry Doss ❑ $
Minimum 25%13gm*of Contract Amount due upon execution orlhis COWSct. Total Contract Amount $
Maine Purehaceni may not&posit more than one-third of the Contra*Amount.
Customer agrees that,immediately upon completion of the work for each Product,Customer will'ezeeute a Completion Certificate
one for each Product as'defxned by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The House Depot reserves the right to issue a Change Order of terminate this Contract or.any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural .
problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract
Payment Summary: The Payment Summary# included as part of this Contract, sets•forth the total
Contract amount and payments required fur the deposits and final payments by Product(w%applicable),
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract•at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract.Customer agrees to pay The Rome Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WiTHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAVMFNTS MADE, WITHOUT
LImTnN(G THE HOME DEPOT'S OTHER 1tEMFDmS FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understand--that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either
oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed
by(Z)stomer and The Home Depot.Customer acknowledges and agrees that Customer has read,understand%,voluntarily accepts the
terms of and has received a copy of this Avccmeni.
Accepted b : Sub by: i J
•� X
C usto s Signat& Date Sales sultant's Signature Datc
X _ .,....._ Telephone No.—7--o—V � 'V T_!6 !Z
Customer's Signature Date
Sales Consultant License No.
CANCELLATION* CUSTOMER MAY CANCEL THIS �- W applicable)
AGREEMENT W1'1'HOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME ,fib
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS p �
DAY AFTER STGNiNG THIS AGREEMENT. THE
S'1'ATF SIJPPLF MF NT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE LS
SPECIFICALLY PRESC.RIBFD BY LAW . IN
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NOTICE!ADT)MONAt.TERbIS AND CONDITIONS ARE STATED ON THF.RF,%T:RSF;SIDE AND ARE PART OF THi'S CONTRACT
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, The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
' Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): j7 d IJ
Address:_ IS' U)I LsB/V w/
City/State/Zip: t bQ U
Oz34 Phone #: 7 7� 764-2,3 Z
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I atn a employer with 4. E I am a general contractor and I
* have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time). _
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
1K ship and have no employees These sub-contractors have _ $ Demolition
working for me in any capacity. employees and have workers' ,, E
9. ❑ Building addition
[No workers' comp.insurance comp. insurance.
$
required.] 5: We are a corporation and its 10.E Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.WOther du,)
comp. insurance required.]
*Any applicant that checks box#1 must also Fll out the section below showing their workers'compensation policy info ation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site
information.
Insuranrle Company Name: � s �S
Policy#or Self-ins.Lic.* Expiration Date:
Job Site Address: _ City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify.4nder the pajVs and Penakies o er'u that the in ormation provided above is true and correct.
- _ .._..
Sianature: ... . Date ._
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www massgovldia
®Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiy
Name (Business/Organization/Individual): .Vjj Senz,Ge S
Address: G(' aSko,r, h)r,gJ2 Ke_
City/State/Zip: hrew s(ou r 5 Phone#: S d8- - 2-
Are you an employer? Check the appropriate b
ox: Type of project(required):
I.[rI am a employer with 2-0 t 4. F1 I am a general contractor and 1.
employees (full and/or part-time).*_ have hired the sub-contractors 6_ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [].Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers'
[No workers comp.in comp.surance 9_ Building addition
insurance?
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I i.❑Plumbing repairs or additions
myself � 'o workers comp. right of exemption per MGL
Y P 12_❑Ro of repairs
insurance required.]t c. 152, §1(4),and we have no '-ll
employees. [No workers' 13 Other 4e)
comp. insurance required.] ,o
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such_
tContractors that check this box must attached an additional sheet showine the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp_policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: f, Py�-f�tht/j1 D i/2 1�c Co
Policy#or Self-ins..Lic.#: fA)C-017 73 1 q q 1 Expiration Date: t /- 2-n
Job Site Address: 7Z!: City/State/Zip: paw,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25,.k�6f MU c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil.penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day aga' s violator. Be advised that a-copy of this statement maybe forwarded to the-Office of
Investigations of the DIA o(inorance coverage verification.
I do hereby certify and tl air and en at the information provided above is a and correct
Signature: Date:
Phone#: -
Official use only. o not write in this area,to be completed by city or town offlcial.
City or Town: PermitlUcense#
Issuing Authority(circle one):
1)Board of Health 2.Building(Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
— Cr
Office of Consumer Affairs and Business Regulation
10 Parr Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
- _ - Registration: 125893
- Type: Supplement Card
THD AT HOME SERVICES, INC. _ _ ;: Expiration: 802016
ANDREW SWEET = - -
2690 CUMBERLAND PARKWAY SUITE300-_ ':
ATLANTA, GA 30339
Update Address and return card_Mark reason for ehanpe_
A, • zo%a os<>> —1 Address -I Renewal )employment Lost Card
C�fiee � na/C�o�C�aac/ucaeGza -
o�rrumo�uu
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
4- Office of Consumer Affairs and Business Regulation
Registraticac2. _ Type 10 Park Plaza-Suite 5170
Expi4tiesi 3/--0 j Supplement Card
1INI .. �-— pP Boston,MA 02116
THD AT HOME SEjRG1 1NG"W,\
THE HOME DEPOTS "� —VE`RVICES
ANDREW SWEET;-N 'rJ
2690 CUMBERLAND'FAirId1A1'S
GA 30339 Undersecretary Nov i with ut signature
/1 ® DATE(MNIIDDMYY1)
CERTIFICATE OF LIABILITY INSURANCE 071152015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPOWTHE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORfZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsementfs)-
PRODUCER CONTACT
MARSH USA.INC. NAME
TWO ALLIANCE CENTER PHONE A No
3560 LENOX ROAD,SUITE 24M E-MAIL
ATIA TiA,GA 303M6 ADDRESS.
INSURERS)AFFORDING COVERAGE NAIC 2
iDD492HomeD_-GAW-i5-t6 SteadlardI-=('-�,,,,,,,. ,, MU
- INSURER A' """'2'0"7 -
INSURED ." INSURER B:Z0Rd1 AmBriam Insurance Co 16535
THD"AT HOME SERVICES.INC.
DBA THE HOME DEPOTAT-HOME SERVICES INSURMtC:NSWHM9SNMftC0 1
259D CIIMB91AND PARKWAY•SUITE 300 GA 3D339 INSURER D:llfrlth5 Nal)O1ral insueartr2 Ctxr�Iany 7
ATLAA,
# INSURER E'
c -
! INSURER F"
COVERAGES CERTIFICATE NUMBER: Alt-OM746646.13 REVISION NUMBERe
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERN:OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES.DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS-
ILl TYPE OF INSURANCE ' D POLICY NUrdBER POLICY mF Jy ) POuthawp EAP LIMITS
A ' X I COMMERCIAL GENERAL UABe ITY I iGL04897714 OS - i031DirMS D3lO 12D16 9.0A00o
EACH OCCURRENCE 5
•DAGIAG-TOR
CLAIMS-IAADE M OCCUR I PREMISES Ea ocamemm S
IUTATS OF POLICY XS MED EXP(Any ate pelsron) S EXCLUDED
I :OF Slit"SIM PER OCC � 9,60D,000
i f PERSONAL S AOV INJURY S
GaM AGGREGATE LIMIT APPLIES PER: ii '• _ GENERAL AGGREGATE S 9
F-1
POLICY d
❑ ECaT LOG 9,DDgODD
1 PRODUCTS- S
OTHER', 1 I j S
B AUTOMOBILE LIABILITY 1 I :BAP 29MBSI12 103101/Z)15 (MO OIS I COSt81N®SrvGLE uMiT •S 1,ODQl
i I actalE
X ANYAUTO ! BODILYWJURY(Perperson) is
ALLOIN AUTOS BODILY i f SELF INSURED AUTO FiIY DtSG ` BODILY M.IURY(Peraataeat)IS
AUTOS
OWNED j PROPERTY DAMAGE S '
fiIRFDAl1TOS I NON-OWNED
erPERT rt
l ! EtS
UMBRELLA UAB } OCCUR I EACH OCCURRENCE t S
(I t-xcess LIAR ri CLAIMsMADE1 `I AGGREGATE 5
1 DED I RETENnONS
C WORKERS COMPENSATION I JWC0i7731493(AOS) I
0310i2015 D31DI12016- X PER 'oTH i
C AND EMPLOYERS'LIABILITY { STATUM ER
ANY PROPRIETORIPARTNER(EXEQnSV'c Y®N f AJ _'WC0f7731 (AK,Kl',NII.NJ,VT) 03101f2015 031O2016 f,000,DDD
D OFFICERR.t[7+fB-R EXCLUDED? EL F1iCHACCEDHdT S
(Mandatory In NH) {WC017731494(FL) jQ31D112D15 JONDIJ12016 E.L.DISEASE-EA EMPLOYE34 S 1•0w•000
If yes,desct3e under I I
DESCRIPTION OF OPERATIONS betarr k °.iCOMMUGIf on Adcfifia ml Pace j EL DISEASE-POLICY Luau S t•�•�
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD tot.Additional Remarks Sehedulq may l e attached Ir more space Is requrred)
EViDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POUCIES 13E CANCEL LID BEFORE
OBA THE HOME DEPOTAT-HOME SERVICES THE DIpIRATION, DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE VffM THE POLICY PROVISIONS.
ATLANTA,GA 303E
AurHoR>zED REPRESENTATIVE
of Marsh USA Inc
Manashi Mukherjee Luv otza . wc-�r.e>�u
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
rN,
t„E Town of Barnstable *Permit#
Expires 6 nrontht ra ixstte date
., Regulatory Services Fee
u"m Richard V.Scali,.Interim Director
MAY y'Y Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,b,1A 02601
-o"fiN, www.town.barnstable.ma.us ;
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number l
Property Address
XResidential Value of Work$ Minimum fee of$35.00 for work under,$6000.00
m ,
Owner's Name&Address lCE- /`t
r
Contractor's Name 6 Telephone Number
Home Improvement Contractor License#(if applicable) Id to 8- 3 Email:
Construction Supervisor's License#(if applicable) e)z o o 7
Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor.
❑ I am the Homeowner -
I have Worker's Compensation Insurance
Insurance Company Name keg) #dV1Psff,/k—>,F '4 .S .
Workman s Comp:Policy# W ®A/
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box).
❑ Re-roof(hurricane nailed)(stripping old.shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping..Going over existing layers of roof)
❑ Re-side
Replacement Windows/doors/sliders.U-Value 30 (maximum:35)#of windows
C6-
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town departmeurregulations,Le_.Historic,Conservation,etc.
***Nate: Property er 'sign Property Owner Letter of Permission.
A copy of H mprovement Contractors License&Construction Supervisors License is.
required.
SIGNATURE:
TAKEVIN_D\Building ChangesMM S RESS.doc
Revised 061313
HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by:
PLEASE READ THIS CONTRACT THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
908 Boston Turnpike Unit l,Shrewsbury,MA 1545
Branch Name: Boston South Date:4/21/2014 Toll Free 8779033768;Fax 8009863610ME Lic#C 02439 RI Cont.Lic#16427
Branch No: 31 CT Lic#HIC.0565522 MA Home Improvement
Contractor Reg.#126893 Federal ID#
75-2698460
Installation Address: 72 st Joseph st HYANNIS MA 02601
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
M/M madene beeaker 508)367-3810
Home Address: 72 st Joseph st HYANNIS MA 02601
Of different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):
Marketing emails will not be sent from The Home Depot.
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to
buy,and THD At-Home Services,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati
on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract.
by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders ;
(collectively,"Contract"):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
7453413 Windows 7453413 $2,857.80
Minimum 25% Deposit of Contract Amount
due upon execution of this contract Total Contract Amount $2,857.80
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion
Certificate(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each
Customer under this Contract agrees to be jointly and severally obligated and liable hereunder.
Payment Summary: The Payment Summary# 7453413 ,included as part of this Contract,sets forth the total Contract
amount and payments required for the deposits and final payments by Product(as applicable).
GENERAL TERMS AND CONDITIONS
Responsibilities:
The Home Depot:will provide the Products identified above,make arrangements to have the Authorized Service Provider perform
the Installation services in a professional and workmanlike manner,and arrange proper insurances. Unless otherwise expressly ,
provided for herein,Authorized Service Provider will obtain required permits and provide permit numbers.
Customer:will identify any property lines,easements,covenants,underground or overhead utility lines,pre-existing physical or
0130-14 SFC Page 1 of 13
j
r_
Signed imp
M/M marlene beeaker (508) 367-3810
L
4
f
Pap 10 of 13 r
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h 51 F z
FALL
4
a `1
6 �µ
Off,
A'D4i-i!i5 �{.a� 'ggM..
f� {
9 ua a
Fail St.
W-areham, ma 92071,
'
4
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r.
Y{���se t� �g�s�rat�n,val�d`f�r,iard�v�dul use an " `.'
t3# ice, I. ,nsumie ffAl, s auk Mundt R��u� n ��
Iap y .� -
fx 4 -�• Tom' A .y 1 . .
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a $ •fit ;�' "" ,� ,_.
€�t � uut' � atetrefr
May 11, 2013
Barnstable Building Dept.
The following is a list of our approved sub-contractors for The Home
Depot:
Ericsson Torres -:CSSL # 100546 HIC # 163528
Michael Viola — CSSL # 099403 HIC # 140993
Vincent Smith - CS # 106837 HIC # 165927
Timothy Thomas — CS # 51899 HIC # 152121
Ronaldo Solano — CSSL # 101027 HIC # 152206
Joseph Duarte - CS # 70077 HIC # 132349
Douglas Szynal — CSSL # 103950 HIC # 146142
Brian Laroche — CSSL # 100478 HIC # 152612
Joseph McKeon — CSSL# 98863 HIC # 132614
If you have any questions please contact Mike Bedard our permit
coordinator at 508-962-6942 or myself at 617-438-9017.
Si erel
uss one
Bra Installation Manager
THD At-Home Services, Inc.
908 Boston Turnpike• Unit 1 •Shrewsbury, MA 01545
Phone:774-275-2139•Fax:508-845-6076•Toll Free:800-657-5182
The Commonwealth of Massachusetts
Department of Industrial Accidents
t Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:_ bu�Y,
City/State/Zip:14 104b0fVa` d Z39� Phone #: 7 7JI- 76d -2-3 2
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a em to er with 4. ❑ I am a general contractor and I
p y — 6. El New construction
employees(full and/or part-time).* have hired the sub-contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees-and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurarice.1
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation.policy.information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
-^ I am an employer that is providing workers'compensation hisurancefor my employees Below is the policy and job site
information.
Insurancie Company Name: o
Policy#or Self-ins.Lic.,#:. Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of'the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead.to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi y nder the a" s and en . ies of perjury that the information provided above is true and correct.
Si ature. ,.__..:. __ �_.. / ____ _._----_—_—_J Date: _.
Phone#: 77q - 7(o
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
— Boston, MBA 02111 —.
w4 www.mass.gov/dia
W®rkers'..C€ m ensation Insurance Affidavit: g.nilders/Contractors/Electricians/Plumbers
Applicant Information Please Print�,e�ibl�
r
Marne (Business/Organization/Individual):, V"
Address: r� C� �t k
City/State/Zip: t � a 30;3 Phone
Are you an employer?Check the appropriate a a x: Type,of project(required):
4. ( . m general contractor and I
1.❑ I am a employer,with . _ g 6. New construction
employees(full and/or part ttme).� . have hired.the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7." []Remodeling
ship and have no employees., These sub-contractors have S. ❑DemoLtion
workingfor me in an capacity. employees and have workers'
Y p h'• $ 9. ❑Building addition
w .
[No workers' comp. insurance comp.insurance.
We are a corporation and its 10.0 Electrical repairs or additions
re ttired: .. ... ❑ rP
3.❑ I am a-homeowner doing all work officers have exercised their 11.®Plumbing repairs or additions
myself.[No.workers' comp, right of exemption per MGL 12.❑Roof repairs
insurance required:] t c. 152, §1(4),`and.we have no .
employees.[No workers' . 13 Other I�t9 O
comp,.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy i formation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
iContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
information.
Insurance Company Name: Aew 0
Policy#or Self:ins.Lic.#: 0 / ! 10 / Expiration Date:
Job Site Address'. 702 �1�(Ji` C" t7SP4�1 �T City/State/tip:I7
Attach a-copy of'the'workers'compensation policy declaration page(showing the policy number and espir4#i p date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.60 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the.violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA W insurance covers a verification.
I do hereby certify u e ae pains and penalties of perjury that the information provided a0ove il true and correct
Signature: / Date: -//14"'
Phone
Official use only. Do not write in this area,to be completed by city or town official .
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other .
Contact Person: Phone#: _
' e
1,
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10 Park.Plaza► - Suite 5170
Boston, Mamchusetts 02116
146me jmprove oKontractor Region
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The Home t.At-Home Sei
ANDREW SWEET
2690 cUMBERLAND PARKWAY IZ,0 1_ +
ATI.ANTA, GA 30339
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Assessors map and lot number ....a.q.............c 2.l. •• ..... SEPTIC $yS
• �Q�� °��o COMPLIANCENC
ESewage Pefthit number A.-T
� EN�A�Y II STATE
`7MEr R � COBE AND TOWN OF BARNS
2 BAHBSTABLE. i
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6 9 DUILDIAG INSPECTOR
APPLICATION FOR PERMIT TO .........)8.64!�...............................................................................................
TYPEOF CONSTRUCTION ...... .............................................................................................................
�J li........� ................19.� .
TO THE INSPECTOR OF BUILDINGS:
The undersigns her by applies for a permit At....according to the following information:
Location �. .
.A.........................................................................................
c
Proposed Use ..
t i
f: ......................................
Zoning District ..� 1M . ...............................Fire District ..... �. ...�4� :..
.............. .... ...... ...........................................
Name of Owner . ... .. .. ... .. ..................Address .... . .. ..... f..! !....... :
/L
' lc
Name of Builder . e...... .....................Address
.
Nameof Architect ..................................................................Address ......................................c.............................................
Number of Rooms :.......� .......� t —:.......................Foundation ..C..............C'. .......................... . ...................
Exterior ........ A.1/.y.1.,. -.A..............................................Roofing ............. :4ff..................................................
Floors ..... ...... ................................................Interior ...... ........................................................
��y 00\\ .. ` I
Heating ......:(�„t..� .......Y.:!.1........ .�..............................Plumbing ....> ..�. ... .� ................................................ '
6� d�
Fireplace ......./.`-'J IK....................................................Approximate Cost .... ::. ..:................................ . ......
Definitive Plan Approved by Planning Board -------------------_-----------19________. Area .... ...... 5�.....Sn .....
Diagram of Lot and Building with Dimensions �" Fee ....... ff�J1 �
..............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
/ba
-73
a' 4 ,
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
e
Name
Drouin Corp.
16697 one st
No ................. Permit for ............... ... ............... 4
I
single family dwelling
............................................................................... ,
LocationSt. Jose]Rh St.
.. .......................... ...............................
............................ 'annis...................................
?rouin
Owner ............... .......C....o rp.!......................... i
Type of Construction ...............frame.,,,,......._„ s
r
................................................................................
Plot ........................ Lot .................#39........ 4
I
1
October 31 73
Permit Granted ...... ... 19
Date of Inspection�....!�� C!¢.<FBRFP`"19
Date Completed
PERMIT REFUSED i
i
................o................................................. 19 ,
.........Y o1.6...........................................................
................................................................................ r i
r,
............................................................................... C
............................................................................... }
Approved .......................... 19 t
............................................................................... 4
...............................................................................